Consolidate the Diverse Strategies and Advancements for Managing Non-muscle Invasive Bladder Cancer, Focusing on T1 High-grade Cases: A Comprehensive Review

Objective: This comprehensive review examines the impact of diverse scientific approaches employed over the past two decades in the treatment of T1 high-grade bladder cancer. The aim is to assess their influence on clinical outcomes through a systematic review.

Literature Search Methodology: Through a systematic approach, a literature review spanning 2000 to 2020 was conducted across various databases including PubMed, Medline, and Embase. This review focuses on randomized controlled trials (RCTs), clinical trials, research and review articles, and original contributions that address the diagnosis and management of non-muscle invasive bladder cancer (NMIBC) within the last two decades. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and PICOS criteria (Population, Intervention, Comparators, Outcomes, and Study Design), we identified and sourced over 573 studies. Ultimately, 85 articles were selected for analysis, encompassing 19 prospective trials, 44 RCTs, original and research articles, a review article, and clinical trials. Retrospective studies were intentionally excluded to minimize bias.

Results: The review delves into the role of biomarkers in early NMIBC patient identification for predicting recurrence and progression. Notably, P-cadherin expression and other markers show promise in recurrence and progression prediction. Risk stratification emerges as a pivotal tool to enhance NMIBC patient outcomes, although refinements are still necessary.

Studies underscore the positive impact of fluorescence diagnostic cystoscopy (FDC) and Photodynamic diagnosis (PDD) on recurrence-free survival, although their influence on progression and overall outcomes is less evident. Consensus points to intravesical BCG therapy as the most transformative treatment for altering high-grade T1 disease trajectories, particularly in terms of progression. Re-TURBT after 2-6 weeks is increasingly endorsed by international societies. Its potential to enhance survival is debated, as it offers improved sampling for pathologic reading and detection rates.

While numerous articles underscore the benefits of early cystectomy for NMIBC patients, contrasting viewpoints suggest that cystectomy could potentially result in excessive treatment. The consensus underscores the necessity for well-defined selection criteria, as postponing cystectomy for NMIBC is associated with a more unfavorable prognosis in comparison to timely surgical intervention.

Conclusions: This comprehensive review evaluates the outcomes attributed to scientific advancements in managing NMIBC patients over the past two decades. Variability in outcomes among T1 bladder cancer patients arises from tumor heterogeneity and clinical staging. Despite advances in diagnosis, risk stratification, and management, larger studies are required to better comprehend and tailor treatment for this patient subset, with the goal of minimizing both over-treatment and under-treatment.